The Medical History

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name, DOB and what they like to be called
• Explain and obtain consent

Presenting complaint

• Determine symptoms which brought patient in
• Start with an open question

History of presenting complaint

• Explore each symptom (including further symptoms you elicit in system reviews)
  • Timeframe
    • Duration
    • Onset (sudden or gradual)
    • Progression
    • Timing (intermittent or continuous)
  • Symptom-specific questions, e.g. SOCRATES for pain (see exploring symptoms)
• Relevant system reviews to determine presence/absence of possible associated symptoms (see systems review)

Past Medical / Surgical History

• Ask generally about medical conditions and past operations
• Ask specifically about conditions/risk factors relevant to differentials (e.g. hypertension, diabetes etc. for cardiac chest pain)
• For relevant conditions, find out more information, for example:
  • When diagnosed
  • What treatment
  • Control of condition

Drug History

• Allergies (including reactions)
• Medications (with doses and frequencies) – include over-the-counter medications and natural remedies

Family History

• Ask family history of conditions relevant to differentials

Social History

• Living situation
  • House/flat/nursing home
  • Who’s at home
  • Carers
  • Who does activities of daily living
  • Mobility aids
• Occupation ± occupational history if relevant
• Smoking and alcohol:
  • Smoking (calculate pack years)
  • Alcohol (calculate weekly units)
  • Recreational drugs (if relevant)
• Travel/pets/hobbies/sexual history if relevant

Other Points

• Ideas, concerns, expectations, feelings: this is a vital part of the history and should be integrated throughout
  • Ask ideas and concerns about condition
  • Ask expectations from consultation
  • Consider the patient’s thoughts and feelings
• Remember to pick up on cues throughout history
• Some specialties have specific histories with additional parts (see specific histories)
• Finish by summarising and ask the patient if they have any questions

Try a few questions…

A 34 year old female patient presents with abdominal pain. How would you explore the history of the presenting complaint?

You should explore the symptom of abdominal pain by establishing the timeframe and using SOCRATES:

• Site
• Onset: sudden or gradual
• Character: sharp/stabbing, burning, cramping, pressure, ache, etc.
• Radiation
• Associated symptoms
• Timing: intermittent or continuous; any triggers?
• Exacerbating/relieving factors: e.g. movement, change with bowel movement
• Severity: rating out of 10

Once you have explored the symptom, you should undertake a relevant systems review. Which questions would you ask?

For abdominal pain the relevant systems to review would be:

• General:

  • Fevers, fatigue

• Gastrointestinal:

  • Weight: weight loss, appetite change
  • Work down body: dysphagia, nausea/vomiting, indigestion/heartburn, bowel habit, tenesmus, blood/mucus in stool, flatus

• Urinary:

  • Frequency, dysuria, urgency, haematuria, change in urine

• O&G:

  • PV bleeding, PV discharge, Pelvic pain, Possibility of Pregnancy

What would be in your differential diagnosis for abdominal pain? Ensure you structure your answer.

• Gastrointestinal causes: appendicitis, gallstones, pancreatitis, peptic ulcer/gastritis, diverticulitis, bowel obstruction, constipation, IBD
• Urological: UTI, pyelonephritis, renal colic
• O&G: ectopic pregnancy, pelvic inflammatory disease, endometriosis

Why don’t you try some OSCE stations!

1. Chest pain history
2. Haemoptysis history
3. Change in bowel habit
4. Leg pain
5. And there’s lots more here!